Our Lady S Hospital for Sick Children

OUR LADY’S CHILDREN’S HOSPITAL, CRUMLIN, DUBLIN 12. A Teaching Hospital Telephone: 409 6314 Facsimile: 409 6126

PRIVATE AND CONFIDENTIAL APPLICATION FORM (NCHD) OLCHC (Please note: This Hospital is a Non Smoking Hospital) PLEASE NOTE: Application form must be completed in full in order to be processed

Surname First Name Middle Name

NEXT OF KIN: RELATIONSHIP TO YOU:

CURRENT MAILING ADDRESS: PERMANENT ADDRESS:

TEL: (H) (W) (MOBILE)**

EMAIL ADDRESS:

IF CONTACTABLE BY FAX PLEASE GIVE NO.:

CITIZENSHIP STATUS

IRISH EU COUNTRY If other, please specify

IS THERE ANY RESTRICTION ON YOUR RIGHT TO WORK IN IRELAND? YES NO

If yes, give details:

LICENSING

Are you currently licensed to practice medicine in the Republic of Ireland ?

YES / NO General Registration/ Specialist Registration

If YES – Medical Council No. & Expiry date:

Please list location and type of license of any other country in which you have been licensed to practice medicine: OUR LADY’S CHILDREN’S HOSPITAL,CRUMLIN IS AFFILIATED WITH: UNIVERSITY COLLEGE DUBLIN AND THE ROYAL COLLEGE OF PHYSICIANS/ SURGEONS IN IRELAND APPLICATION FOR POSTGRADUATE TRAINING

REGISTRAR POSTS ONLY

Paediatric Intensive Care Unit Orthopaedic Surgery Registrar (Ref. 001) (Ref. 004)

Anaesthetic Registrar (Ref. 002)

Cardiothoracic Surgery Registrar (Ref. 003)

SENIOR HOUSE OFFICER POSTS ONLY

SHO in Cardiothoracic Surgery (Ref. 005) The following section must be completed by Graduates of Medical Schools outside of Ireland What is your native language? Other languages spoken: Are you proficient in English? YES / NO EDUCATION AND TRAINING EDUCATION: Medical School INSTITUTION AND LOCATION: YEAR OF GRADUATION: DEGREE TITLE: TRAINING: Present Position (if any) POSITION: INSTITUATION AND LOCATION: DATES:

POST GRADUATE EXAMINATIONS PASSED (please tick) Diploma in Child Health Membership Royal College of Physicians - Part 1 (UK or Ireland) - Part 2 Fellowship, Royal College of Surgeons - Section A - Section B Other – Please Specify

REFEREES – Please list three referees (with their work addresses/Titles and telephone numbers)-****IMPORTANT*** **Example: REFEREES: Dr Joe Bloggs, Consultant Neonatologist, Our Lady’s Children’s Hospital Crumlin, D12/ 4092000 YOUR DETAILS: 13th January 2014 to 12th July 2014 . Position: Registrar / Speciality: Neonatology 1. Referee: Title: Email Address: Address: Period worked with Referee FROM: ………/……../……. TO …../……../……. Your Position/Speciality:______2. Referee: Title: Email Address: Address: Period worked with Referee FROM: ………/……../……. TO ………/……../……. Your Position/Speciality:______3. Referee: Title: Email Address: Address: Period worked with Referee FROM: ………/……../……. TO ………/……../……. Your Position/Speciality:______

DISCIPLINARY Have you been subject to any disciplinary action by any licensing authority? YES / NO If YES, please give details in accompanying letter.

HEALTH Do you have any health problems which would interfere with your ability to function in the position for which you are applying? YES / NO IF YES, GIVE DETAILS:

I certify that the information in this application is complete and correct Signature: Date: Please enclose the following with completed application form: a) Copies of Certificates / letter relating to exams in Section (b) Photocopy of your Medical Degree c) Photocopy of registration with Irish Medical Council (d) 3 copies of your Curriculum Vitae

APPLICATIONS WILL ONLY BE ACCEPTED BY POST Completed Applications & 3 copies of your C.V should be posted to: Medical Human Resources Department, Our Lady’s Children’s Hospital, Crumlin, D.12. Telephone: +353 1 4096314